Page 17 - Cover letter and evaluation for Darlene Hoover

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

F
C D F G (High K L M N
Deductible)

$1,475 $1,300 $1,500 $1,300 $600 $800 $1,050 $1,350 $1,125

99.7% 97.1% 100.0% 97.3% 43.5% 53.5% 72.6% 84.2% 71.5%
Co-Payments and Cost-Sharing

You pay You pay
nothing nothing

You pay You pay You pay

You pay You pay $85.25 a $42.63 a nothing You pay
nothing nothing After you day day nothing
have paid You pay You pay
You pay the plan's 2.5% & 1.25% &
nothing $2,300 $2.50 $1.25
deductible, You pay You pay
You pay you will $682 $341 You pay $682
nothing have no
You pay You pay further cost- You pay You pay You pay $185 You pay $185
$185 $185 sharing for $185 $185
Medicare- You pay 10% You pay 5% Only costs are
You pay covered of Medicare- of Medicare- You pay $20 for doctor's
nothing services. approved approved nothing office visits; $50
amount amount for an ER visit
You pay
nothing
Not
Not covered Not covered Not covered Not covered Not covered
covered

Some Some Some Some Some Not Some Some
coverage* coverage* coverage* coverage* coverage* covered Not covered coverage* coverage*

You pay You pay You pay You pay You pay You pay You pay 5% You pay You pay
nothing nothing nothing nothing nothing 10% of cost of cost nothing nothing
2019 high-deductible amount = $2,300

2019 Out-of-Pocket Limit*** $5,560 $2,780

*** Out-of-pocket limits do not include plan premiums. Neither do they apply to services that are not covered. In Plans K and L, for
instance, the Part B deductible is not covered. Thus any money you spend for the deductible will not count toward the OOP limit.

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